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15 Vascular Access andControl inTrauma oftheNeck
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origin, care should be taken to avoid injury to the
thoracic duct and the recurrent laryngeal nerve on
the right.
15.12 The Subclavian Arteries
Traumatic injuries to the subclavian arteries are
associated with a high pre-hospital mortality of up
to 80%, and of those who survive transfer to hospital, 15% die in the peri-operative period [14].
Open surgical access is achieved via a median sternotomy, but the use of a remote occlusion balloon
placed via the femoral or brachial arteries should
be considered to attain proximal control. Primary
ligation of the subclavian artery can be considered
in times of extremis as the upper limb rarely suffers from ischaemia due to an embryologically
well-collateralised upper limb arterial supply.
15.13 Venous Injuries intheNeck
Additional venous injuries are commonly associated with cervical arterial trauma due to the close
proximity of the internal and external jugular
veins. In contrast to injuries to the iliac veins and
inferior vena cave, venous injuries in the neck are
reasonably easier to access and control without
signicant long-term sequalae. The venous system of the neck is of low-pressure and injured
jugular vessels will often tamponade or occlude,
but if required, can be surgically ligated without
consequence [15]. If primary repair is a feasible
option, haemorrhage can be controlled with the
application of pressure on either side of the vessel rent and either side of the vein picked up in
allis forceps to lift it out of the wound bed. Repair
with a 5/0, 6/0 or equivalently sized prolene
suture can then be performed.
15.14 Principles ofVascular Surgery
inCases ofBlunt Neck Trauma
Blunt cerebrovascular vascular injury (BCVI)
presents a clinical challenge as it is often occult
and difcult to diagnose due to the relative pau-
city of external symptoms and signs. Most injuries are diagnosed after signs of cerebral
ischaemia become apparent, resulting in a neurological morbidity of up to 80% and associated
mortality of 40% [16]. The modied Denver criteria identify patients at particular risk of BCVI
to include those involved in high energy transfer
mechanisms with Le Fort II or III midface fractures, base of skull fractures, cervical spine fracture, subluxation or ligamentous injury at any
level, near hanging with anoxic brain injury, seat
belt abrasion, or any other soft tissue injury to the
anterior aspect of the neck causing swelling or
Glasgow coma scale score<6 indicating severe
traumatic brain injury [17]. Clinical signs suggestive of BCVI include obvious haemorrhage
from the neck, nose or mouth, cervical bruit,
expanding haematoma, focal neurological decit,
cerebrovascular accident seen on CT brain, or
neurological signs incongruous with CT head
ndings [17].
Treatments for BCVI can be stratied and
graded to help guide management, with the Blunt
Carotid Arterial Injury Grading scale being a useful tool in common use [18]. As a general guide,
however, non-ow limiting intimal disruptions
and dissections seen at the time of trauma can be
managed with serial clinical examination, interval imaging, and close follow-up. Anti-platelet
agents should be commenced to help stabilisation
of the vessel wall, and the patient should be
examined for signs of distal embolisation of clot
at which point mechanical thrombectomy or anticoagulation may also be considered. Late, occult
features of an injured vessel include development
of a pseudoaneurysm, which may be managed
via endovascular deployment of a covered stent
graft if anatomically suitable, or primary repair
with aneurysmorrhaphy or placement with an
autologous venous, or prosthetic (ePTFE) interposition graft, but these procedures should be
performed by those with the training and expertise to undertake them.
Top Five Take Away Points
1. Priorities incorporate ATLS principles secur-
ing the airway, maintaining ventilation, controlling haemorrhage, and treating shock.
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P. Ghaly et al.
2. Zones 1 and 3 are challenging zones for vascular access, exposure, and control. A multidisciplinary approach including the
involvement of vascular, cardiothoracic, and
neurosurgeons/neuro-interventional surgeons
must be anticipated and sought early.
3. Temporising measures with the use of shunts
and balloon occlusion catheters can be used.
4. Clinicians should have a high index of suspicion for blunt cerebrovascular injuries (BCVI)
in those patients who have had high-energy
transfer injuries.
5. Venous injuries can be treated centrally with
endovascular-covered stents, and distally can
be ligated if encountered intra-operatively.
References
1. Beard JD, Gaines PA, Loftus I.Vascular and endovascular surgery E-book: companion to specialist surgical practice. Elsevier Health Sciences; 2013.
2. Nowicki JL, Stew B, Ooi E.Penetrating neck injuries:
a guide to evaluation and management. Ann R Coll
Surg Engl. 2018;100(1):6–11.
3. Newton K.Penetrating neck injuries: Initial evaluation and management In: Grayzel J, ed. UpToDate,
Waltham, MA. Accessed 5 Dec 2021: UpToDate;
2021.
4. Apffelstaedt JP, Müller R. Results of mandatory
exploration for penetrating neck trauma. World J
Surg. 1994;18(6):917–9. discussion 20
5. Tisherman SA, Bokhari F, Collier B, Cumming J,
Ebert J, Holevar M, et al. Clinical practice guideline: penetrating zone II neck trauma. J Trauma.
2008;64(5):1392–405.
6. Müller M, Schmitz BL, Pauls S, Schick M, Röhrer S,
Kapapa T, etal. Variations of the aortic arch- a study
on the most common branching patterns. Acta Radiol.
2011;52(7):738–42.
7. Hornez E, Boddaert G, Ngabou UD, Aguir S, Baudoin
Y, Mocellin N, et al. Temporary vascular shunt for
damage control of extremity vascular injury: a toolbox
for trauma surgeons. J Visc Surg. 2015;152(6):363–8.
8. Burgess CA, Dale OT, Almeyda R, Corbridge RJ.An
evidence based review of the assessment and management of penetrating neck trauma. Clin Otolaryngol.
2012;37(1):44–52.
9. Demetriades D, Theodorou D, Cornwell E, Berne TV,
Asensio J, Belzberg H, etal. Evaluation of penetrating
injuries of the neck: prospective study of 223 patients.
World J Surg. 1997;21(1):41–7; discussion 7–8
10. Kazimierczak A, Rybicka A, Rynio P, Gutowski P,
Wiernicki I. Cosmetic effects of skin-crease camouage incision versus longitudinal incision following carotid endarterectomy. Wideochir Inne Tech
Maloinwazyjne. 2018;13(1):102–10.
11. Deck M, Kopriva D.Patient and observer scar assessment scores favour the late appearance of a transverse
cervical incision over a vertical incision in patients
undergoing carotid endarterectomy for stroke risk
reduction. Can J Surg. 2015;58(4):245–9.
12. Reid JD, Weigelt JA. Forty-three cases of vertebral
artery trauma. J Trauma. 1988;28(7):1007–12.
13. Thomas GI, Anderson KN, Hain R, Merendino
KA.The signicance of anomalous vertebral-basilar
artery communications in operations on the heart and
great vessels: an illustrative case with review of the
literature. Surgery. 1959;46:747–57.
14. Demetriades D, Rabinowitz B, Pezikis A, Franklin J,
Palexas G. Subclavian vascular injuries. Br J Surg.
2005;74(11):1001–3.
15. Kumar SR, Weaver FA, Yellin AE.Cervical vascular
injuries: carotid and jugular venous injuries. Surg Clin
North Am. 2001;81(6):1331–44, xii–xiii
16. Davis JW, Holbrook TL, Hoyt DB, Mackersie RC,
Field TO Jr, Shackford SR.Blunt carotid artery dissection: incidence, associated injuries, screening, and
treatment. J Trauma. 1990;30(12):1514–7.
17. Geddes AE, Burlew CC, Wagenaar AE, Bif WL,
Johnson JL, Pieracci FM, etal. Expanded screening criteria for blunt cerebrovascular injury: a bigger impact
than anticipated. Am J Surg. 2016;212(6):1167–74.
18. Bromberg WJ, Collier BC, Diebel LN, Dwyer KM,
Holevar MR, Jacobs DG, etal. Blunt cerebrovascular
injury practice management guidelines: the Eastern
Association for the Surgery of Trauma. J Trauma.
2010;68(2):471–7.
Maxillofacial Trauma
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fortheGeneral Surgeon
PeterAquilina
16
Oral and maxillofacial trauma is frequently a
component of major trauma. In theatres of war,
such injuries can account for a disproportionate
volume of casualties and subsequent consumption of resources and effort. This chapter will not
provide detailed protocols for the denitive management of patients with maxillofacial and dental
trauma. It is designed to aid the general surgeon
in the initial management of these patients,
potentially in a remote setting, prior to transfer to
a larger centre for denitive care.
16.1 Emergency Management
ofthe Patient withIsolated
or Concomitant Maxillofacial
Trauma
The early management of trauma as per the
ATLS/EMST protocols apply to the patient with
maxillofacial injuries; however, the presence of
trauma to the face does introduce some dilemmas
[1–3]. In particular, there can be a conict
between the management of the airway and the
ATLS protocols regarding the management of
actual or potential c-spine/thoracic/lumbar spine
and pelvic trauma.
P. Aquilina (*)
The University of Sydney School of Medicine,
Sydney, NSW, Australia
All trauma to the maxillofacial region puts the
airway at risk to a variable degree. This risk can
evolve from being low at initial presentation to
being high as oedema and haematomas for example develop (Fig.16.1). Patients with facial injuries invariably prefer to sit up and lean forward to
allow blood to drain from their mouth. When
patients are prevented from doing this when
restrained with a spine board and a rigid cervical
collar/head box, the patient’s ability to maintain
their airway is restricted (Fig.16.2a–c). This situation is further exacerbated by the risk of vomiting [1, 3] which is frequently seen in this cohort
of patients due to the common presence of alcohol [4], and the effect of swallowing blood arising from the facial injuries. Vomiting occurring
in a patient restrained as above can lead to aspiration or airway loss.
The presence of fractured or avulsed teeth also
poses a potential risk to the airway. Thorough suctioning of the mouth and upper airway should be
done, and any missing teeth or fragments of teeth
should be accounted for. If a tooth is missing, or a
fragment froma tooth has been fractured offand
is unacounted for, chest lms need to be obtained
to exclude aspiration of these fragments.
Aids to airway management may be usefulin
some situations. Guedel airways are poorly tolerated and may precipitate vomiting [1, 2].
Nasopharyngeal airways are better tolerated, and
despite common opinion, they are associated
with a low risk of cranial intubation [5]. A poten-
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
B. Ashford (ed.), Head and Neck Surgery for General Surgeons,
https://doi.org/10.1007/978-981-19-7900-2_16
221
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Fig. 16.1 CT scan axial view of a sublingual haematoma
compromising airway patency. Note the ETT tube
P. Aquilina
tial problem with nasopharyngeal airways is their
association with epistaxis. Bag and mask ventilation is commonly utilized but can be difcult in
the presence of facial fractures due to altered
anatomy and the presence of bleeding.
Early clearance of spine and pelvic injuries is
imperative to allow patients with facial trauma to
sit upif able. Alternatively, consideration needs
to be given to early denitive airway management. The preferred denitive airway is an oral
endotracheal tube [2]. Concerns with potential
spinal cord injury occurring during intubation in
the presence of a c-spine injury are valid but
unlikely to occur if manual in line stabilization is
used [6]. Nasal intubation is not associated with
an increased risk of cranial intubation [7] but is
seldom used due to the increased technical
difculty.
Emergent surgical airways are rarely required.
Needle cricothyroidotomy can be used as a tempo-
a c
b
Fig. 16.2 (a) A patient after a high speed motorbike acci-
dent with spinal precautions in situ. Not the presence to
grass and foreign material in the wound. (b) The same
The 3D CT reconstruction of this patient demonstrating
signicant skeletal disruption
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223
rizing measure. Surgical cricothyroidotomy is the
preferred surgical airway in a trauma setting [8].
16.1.1 Basic Dental Anatomy
There are normally 32 adult teeth (secondary)
and 20 deciduous (primary teeth). There may be
more or less teeth present due to congenital
absence, loss due to dental disease, previous
trauma or extraction for orthodontic reasons and
the presence of supernumerary (additional teeth)
teeth. Each tooth has three basic layers: an inert
outer enamel layer, a layer of dentine and an
inner dental pulp.
Each tooth is supported within the bony alveolar processes (alveolus) of the maxilla and mandible by the periodontal ligaments. The
neurovascular and lymphatic supply to the dental
pulp of each tooth enters primarily via the apical
foramen(s) at the end of each root. Disruption of
this supply can result in inammation or necrosis
and infection of the dental pulp. Teeth are richly
innervated with branches from the mandibular
and maxillary trunks of the trigeminal nerve and
noxious stimuli can result in exquisite pain.
Teeth can be individually named (i.e., upper
left central incisor) butinternationally the most
commonly used identication system is the
FDI (World Dental Federation) system. In this
system, the dental arches are divided into four
quadrants starting at the upper right, which is
denoted quadrant 1, and moving in a clockwise
fashion (looking at the patient) to the upper left,
which is denoted quadrant 2, the lower left, which
is denoted quadrant 3, and the lower right which
is denoted quadrant 4. Within each quadrant,
there are normally eight teeth. These teeth are
numbered 1–8 commencing at the central incisor
and proceeding posteriorly in a sequential fashion to the third molar tooth. It is thus able to identify a tooth by giving the quadrant it is in and the
number it is in that quadrant. For example, the
lower right second molar is the seventh tooth in
the lower right quadrant and is designated as
tooth 47.
16.1.2 Dentoalveolar Injuries
The detailed management of these dental injuries
is beyond the scope of this chapter and early
referral to a dentist is indicated. Nonetheless,
there are steps that can be taken to maximise
patient recovery from these injuries. The following applies to the adult dentition (permanent
teeth). Deciduous teeth should not routinely be
replanted due to the risk of damage to the underlying and developing permanent teeth.
16.1.2.1 Classication
1. Isolated tooth injury
(a) Ellis class I: Trauma isrestricted to the
enamel only. The dentine layer is not
exposed.
(b) Ellis Class II: There is a fracture
ofbothenamel and dentine, howeverthe
dentalpulp is not exposed.
(c) Ellis class III: There is afracture of the
tooth involving all three layers and exposing the pulpal tissues.
After accounting for any lost tooth structure and where required excluding aspiration, the initial management of these
injuries is supportive whilst waiting for
denitive dental review. Analgesia and
antibiotic coverage may be indicated.
Large portions of tooth should be kept as a
dentist may use them as a part of a repair.
2. Subluxation
Provided the tooth is not mobile, no acute
management is required. If the tooth is
mobile, splinting of the tooth until dental
review occurs is indicated. Temporary splinting can be achieved by moulding aluminium
foil around the mobile tooth and the adjacent
teeth.
3. Intrusion
If the tooth is not mobile, no acute management is required prior to referral.
4. Extrusion
The tooth should be pushed back into the
socket and then a temporary splint placed
until dental review occurs. Inltration with
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P. Aquilina
local anaesthetic can assist; however, inltration is less effective in the mandible compared to the maxilla due to the increased
thickness of bone between the tooth socket
and the bone surface.Obtaining reliable local
anaesthesia of the mandibular teethrequires
the use of a nerve block techniqueto anaesthetise the inferior alveolar nerve.
5. Avulsion
Avulsion of an adult tooth is a dental emergency [9]. The tooth should be handled by
the crown and the root should not be touched.
The reason for avoiding handling of the root
is to maximise the survival of periodontal
ligament cells on the root surface which are
required for successful replantation. If the
tooth is dirty, it should be gently rinsed in
milk or saline without scrubbing or manipulating the surface of the root. Replant the
tooth as soon as possible without removing
the blood clot in the tooth socket [9]. Teeth
replanted within 15min of avulsion have the
best prognosis [10]. If replantation is not
immediately possible, store the tooth in cool
milk. Periodontal ligament cells will remain
viable for up to 6 h when stored this way
[10]. Alternatives to milk such as saliva or
saline can be used, but the survival of the
periodontal ligament cells in these cases is
only about an hour. It is important to not
rinse the tooth with water or store the tooth
in water. Following replantation, a temporary
aluminium foil splint should be applied, and
urgent dental review organised. Antibiotic
treatment should be commenced.
Doxycycline is preferred as it has documented efcacy in reducing the risk of root
resorption post replantation [10]. In children
younger than 8 with a developing dentition,
or in patients in which tetracyclines are contraindicated, amoxicillin can be used. The
use of a chlorhexidine mouth wash 8 hourly
is also recommended.
6. Root fractures
These have a poor long-term prognosis. If the
remaining tooth portion is mobile, it can be
splinted with aluminium foil as described
above.
7. Dentoalveolar fractures
These are fractures of the alveolar bone. The
teeth contained within the bone segment may
be uninjured. Treatment pending maxillofacial review is supportive, consisting of analgesia, antibiotics, and splinting, if possible, to
minimize movement. Gentle reduction under
local after administration of local anaesthesia
may be performed if it is judged that a segment is signicantly displaced.
16.1.3 Maxillofacial Injuries
Maxillofacial injuries often accompany dental
trauma and one may be indicative of the presence
of the other. Equally, a fracture of the bony skeleton
of the face should also be taken as a strong indicator of the likelihood of both head injury (closed or
open) or of injury to the cervical spine. The facial
skeleton comprises multiple bones and is arbitrarily
divided into the areas we have outlined below. In
clinical practice, it is common to have fractures of
multiple regions. In this section, we outline the
various components of the facial skeleton and
the associated soft tissues and discuss the acute
management of injuries to these tissues.
1. Frontal sinus.
2. Orbits.
3. Zygoma.
4. Nasal bones.
5. Maxilla.
6. Mandible.
7. Soft tissue.
(a) Eyelids.
(b) Lips.
(c) Tongue.
(d) Oral mucosa.
(e) Facial skin.
16.1.3.1 Frontal Sinus
Relevant Anatomy
The frontal sinus has an outer table covered by
skin and an inner table forming the anterior wall
of the anterior cranial fossa (Fig. 16.3). It is
drained via the nasofrontal ducts into the nose.
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Fig. 16.3 Intra-operative view of reconstruction of the
anterior frontal sinus table demonstrating the relation
between the frontal sinus and the brain
Investigations
1. Clinical examination directed towards cranial
pathology.
2. CT scan with ne (0.75–1.0mm) cuts.
Management
The presence of an anterior table fracture indicates that signicant energy was involved in the
injury and intracranial pathology should be
looked for. Denitive treatment is complex and
varies depending on the status of the posterior
table and the functional status of the nasofrontal
ducts. Brief debridement and closure of soft tissue is indicated prior to referral to denitive maxillofacial surgical care.
16.1.3.2 Orbital Fractures
Relevant Anatomy
The bony orbit contains and protects the globe
and its associated structures. The roof of the orbit
forms the oor of the frontal sinus and the anterior cranial fossa. The optic nerve and its supporting structures enter via the optic canal in the
greater wing of the sphenoid bone. Several
important structures enter the orbit via the superior orbital ssure including the trochlear nerve
(Cranial Nerve IV), the oculomotor nerve (CNIII)
and the abducens nerve (CN VI). Injury to the
superior orbital ssure and its contents is seen in
high energy injuries and should prompt further
investigation for other injuries.
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Fig. 16.4 A dilated and non-responsive right pupil post
fracture of the right orbit
The oor of the orbit forms the roof of the
maxillary sinus. The inferior orbital nerve, a
branch of the ophthalmic division of the trigeminal nerve travels through the oor, variably
encased in bone, to exit via the infraorbital foramen on the anterior maxilla where it supplies a
portion of the skin of the cheek and lateral nose
with sensation.
Investigations
Clinical examination to determine the presence
of vision-risking injuries is mandatory. Wherever
possible, assessment of visual acuity should be
performed and recorded. Pupillary size and
response, including direct and consensual reexes
should be documented (Fig. 16.4). The globes
must be visualised to exclude the presence of
globe injury (Fig.16.5).
The function of the extra-ocular eye muscles
should be determined by assessing the range of
motion of the eyes, noting any restriction in
movement and diplopia.
Pupillary responses can be abnormal secondary to cranial pathology, injury to the oculomotor
nerve, the presence of opioids or mydriatics, and
injury to the optic nerve. The cause of an abnormal pupillary response must be determined and
managed appropriately.
Diplopia is usually due to mechanical restriction of one or more of theextra-ocular muscles
due totheir entrapment in fracture lines or due to
oedema. Rarer but more urgent causesof diplopia
are retinal detachment or lens dislocation.
Diplopia due to mechanical restriction of globe
movement disappears on covering either eye.
Diplopia that persists on covering an unaffected
eye is a signicant clinical ndingthat warrants
opthalmological review.
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Fig. 16.5 Globe trauma occurring in the presence of a
fracture of the left orbit
A CT scan of the facial skeleton including the
orbits should be obtained.
Management
General supportive care is indicated prior to denitive maxillofacial surgery care. Patients should
be advised not to blow their nose in order to avoid
the development of surgical emphysema.
Management should be directed to addressing
conditions that threaten vision. Specic ndings
of note include
(a) Globe trauma. Trauma to the globe needs
urgent opthalmological review.
(b) Retrobulbar haemorrhage.
Retrobulbar haemorrhage is a compartment
syndrome of the orbit. It is marked by pain,
proptosis, decreasing visual acuity and
altered pupillary response. It is a vision-
P. Aquilina
Fig. 16.6 Hyphaema
threatening emergency requiring urgent
management.
Management includes medical treatment aimed
at reducing orbital pressures and surgical management directed at increasing orbital volume.
Medical management aims to decrease compartment pressure within the orbit andconsists of high-dose steroids, acetazolamide
and mannitol.
Emergent surgical management consist of
lateral canthotomy and cantholysis to allow
the orbital contents to come forward, thus
increasing the effective volume (and reducing the compartment pressure) of the orbit.
(c) Lens dislocation warrants ophthalmological
advice.
(d) Retinal detachment warrants ophthalmologi-
cal advice.
(e) Hyphaema (Fig. 16.6) (blood in the anterior
chamber) warrants ophthalmological advice.
Denitive management depends on the degree
of anatomical disruption, the amount of functional
impairment and patient preference. It may involve
open reduction and internal xation and/or orbital
oor reconstruction. In patients with no functional decit, some patients choose to accept a
cosmetic defect rather than have correctivebone
reconstructivesurgery.
16.1.3.3 Zygoma
Unless it is an isolated arch fracture, fractures of
the zygoma always involve the orbit as the zygo-
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matic bone forms part of the orbital skeleton. As
such, acute management should be directed to
orbital injuries as outlined above.
16.1.3.4 Nasal Bones
Injuries to the nasal bones are common and rarely
pose signicant acute issues. Occasionally severe
epistaxis can occur requiring posterior nasal
packing or the use of a proprietary device such as
a “Rapid Rhino” (Smith and Nephew).
16.1.3.5 Maxillary Fractures
Relevant Anatomy
There are two maxillary bones on either side of
the midline. They contribute to the orbital skeleton superiorly, the nasal anatomy medially and
the dentition inferiorly. The maxillary sinuses are
located within the maxillary bones. The maxillary bones are richly innervated and have an
excellent blood supply.
The two maxilla join at the midline to form a
signicant portion of the middle third of the face.
The maxilla and its associated structures sit on
the anterior skull base which is at an approximate
45° slope.
Maxillary fractures are traditionally classied
as le Fort level fractures I, II and III, based on the
level of the fracture; however, this is not particularly useful in an acute setting and pure discrete
Le Fort fractures are rarely seen (Fig.16.7).
Fig. 16.7 Maxillary fractures involving several le Fort
levels as well as extending to the ZMC and orbits
Investigations
Clinical examination may reveal malocclusion
and the maxilla may be mobile.
CT scans are required with ne cuts.
Management
Unless the airway is affected, or there is associated orbital injury, management in the acute setting is supportive. Rarely, the maxilla may be
displaced down the slope of the anterior cranial
base resulting in airway compromise. If this
occurs, the maxilla can be reduced by inserting
two ngers via the mouth behind the posterior
choanae and pulling anteriorly whilst maintaining spinal precautions.
Denitive management in displaced fractures
usually involves open reduction and internal xation. In some edentulous patients, surgical reduction can be avoided, and the changed skeletal
relationship can be corrected by adjusting or
making the patient a new denture.
16.1.3.6 Mandibular Fractures
Relevant Anatomy
The mandible is an arch-shaped bone that articulates with the skull bilaterally at the temporomandibular joints. The inferior alveolar nerves
enter the body of the mandible bilaterally at the
lingual foramen, travel through the body of the
mandible and exit via the mental foramen to
become the mental nerve. The inferior alveolar
nerve is a sensory branch of the mandibular division of the trigeminal nerve and supplies sensation to the majority of the mandible and its teeth.
The lingual nerve supplies the lingual mucosa of
the mandible with sensation.
Structural weak points of the mandible occur
at the condylar necks, the mandibular angles and
the parasymphyseal areas. Common patterns of
fractures are an angle fracture with contralateral
parasymphyseal fracture and a condylar neck
fracture with a contralateral parasymphyseal
fracture. If a patient presents with an isolated
parasymphyseal, angle ofmandible or condylar
fracture, the above fracture patterns should be
excluded (Figs.16.8 and 16.9).
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Fig. 16.8 An OPG radiograph (orthopantomogram)
showing a typical right parasymphysis and left subcondyar fracture pattern. The right parasymphysis fracture
has been reduced and internally xated, the left subcondylar fracture has had a closed reduction
a
P. Aquilina
Fig. 16.10 The clinical presentation of the patient in
Fig.16.9. Note the obvious malocclusionwith an occlusal
step, and the sublingual haematoma. The presence of a
sublingual haematoma is almost pathognomic of a mandibular fracture
to observation with a soft diet. The use of intermaxillary wire xation (IMF, MMF) has largely been
discarded in modern management with the use of
internal xation predominating care.
b
Fig. 16.9 An OPG showing a typical right angle and left
parasymphysis fracture pattern. Note the previously
treated right parasymphyseal fracture
Investigations
Clinical examination may show a malocclusion
(Fig.16.10). Paraesthesia of the lower lip is common secondary to involvement of the inferior
alveolar nerve. The presence of a sublingual haematoma is very suggestive of an underlying fracture. Plain lms at 90 degrees are sufcient (OPG
and PA mandible), howevera CT scan is commonly obtained.
Management
Airway control and supportive treatment are
required prior to denitive care with a maxillofacial
surgeon. Denitive treatment can range from ORIF
16.1.3.7 Soft Tissue
Soft tissue lacerations are commonly seen, and
many can be managed under local anaesthesia
usingthebasic surgical principles of haemostasis, layered closure, accurate soft tissue apposition and tensionless closure. Fine, non-resorbable
sutures should be used on the skin and removed
within 5days to minimise suture marks. Minimal
debridement of soft tissue should be practiced as
tissue that would be non-viable on the extremities
may well retain vitality on the face due to the rich
vascular supply.
Relevant Anatomy
The face has a rich anastomosing vascular supply
and copious bleeding from facial lacerations is
injury as are the parotid ducts (Figs. 16.11 and
16.12).
Particular care should be taken in the management of lacerations involving the eyelids and the
lips.
(a) Eyelids
The anatomy of the eyelids is complex.
Lacerations of the eyelids are not suitable for
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